Pediatric emergency medicine trisk 2637 2637
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is more sensitive than CT, although both may show normal results in the early
stages of disease. Similarly, EEG may demonstrate focal slowing or epileptiform
discharges localized to the temporal lobes, but absence of such findings does not
rule out herpes encephalitis. Herpes simplex encephalitis causes death or
neurologic sequelae in more than 70% of patients. Treatment with acyclovir (60
mg/kg/day divided q8h daily for 14 to 21 days) has resulted in a decrease in
mortality and some improvement in morbidity. Treatment should be started
empirically for any patient with suspected encephalitis.
Postinfectious encephalitis may follow infection with numerous viruses,
including measles, varicella, influenza, and Epstein–Barr virus. Postinfectious
encephalitis is presumed to be an immune-mediated phenomenon, involving the
white matter of the CNS. Demyelination, the pathologic hallmark of the disease,
may be focal or widespread. The CNS involvement may be confined to a specific
area, as in acute cerebellar ataxia after varicella infection, or may be widespread.
The latter condition is often designated acute disseminated encephalomyelitis
(ADEM). A particularly virulent form with high mortality is known as acute
hemorrhagic leukoencephalitis. A clinical syndrome of encephalopathy after
immunization, particularly with whole-cell pertussis vaccine, is also described,
although epidemiologic evidence has called into question the association with
pertussis immunization. ADEM should be suspected in the patient presenting
with neurologic symptoms consistent with encephalopathy in the setting of a
recent viral infection. MR imaging is the diagnostic modality of choice when
postinfectious encephalitis is suspected.
Several autoimmune-mediated encephalitides have been increasingly identified
in children. These include anti-N-methyl-D-aspartate receptor (anti-NMDAR)
and voltage-gated potassium channel antibody-related encephalitis. Children with
anti-NMDAR encephalitis often present with a constellation of symptoms
consisting of psychiatric symptoms, abnormal movements, seizure, autonomic
instability, and hypoventilation. If anti-NMDAR encephalitis is suspected, further
evaluation is required as it can be associated with tumors, most commonly
ovarian teratomas. Treatment for autoimmune mediated encephalitis typically
involves immunotherapy and/or removal of an identified trigger (i.e., ovarian
teratoma). Early treatment has been associated with favorable outcomes.
